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This paper focuses on how to build up a clinical risk management system in healthcare organizations. It is maintained that, to achieve this result, a change in cultural attitudes is needed. It can be obtained by developing adequate tools for risk analysis, which should focus on the peculiarities of the healthcare systems. A no-blame culture should be shared. This culture is based on some basic assumptions. People make mistakes alongside their best skills and good will, sharing adverse events is a learning opportunity, near misses are free lessons and adverse events are often the outcomes of the system. [ABSTRACT FROM AUTHOR]

This paper focuses on how to build up a clinical risk management system in healthcare organizations. It is maintained that, to achieve this result, a change in cultural attitudes is needed. It can be obtained by developing adequate tools for risk analysis, which should focus on the peculiarities of the healthcare systems. A no-blame culture should be shared. This culture is based on some basic assumptions. People make mistakes alongside their best skills and good will, sharing adverse events is a learning opportunity, near misses are free lessons and adverse events are often the outcomes of the system. [ABSTRACT FROM AUTHOR]

Abstract: In February 2007, three organs from an human immunodeficiency virus (HIV)–positive donor were transplanted at two hospitals in the Tuscany Regional Health Care Service, owing to a chain of errors during the donation process. The heart-beating donor was a 41-year-old woman who died as a result of head trauma. The patient''s history did not highlight any risky behavior. The available data on previous hospital admissions reported a negative result on HIV testing. During the donation process, the result of the lab test performed for evaluation of organ suitability was mistakenly transcribed from positive to negative. This wrong negative result was then included in the donation record without any cross-check. Therefore, the Regional Transplant Center allocated the liver and both kidneys. The patient also donated tissues, and a second laboratory conducted an evaluation of suitability for the tissue banks. During this process, only 5 days after the successful transplantation procedures, the positive HIV result was fed back to the Regional Transplant Center and the previous error discovered. Transplanted patients were immediately assessed and then treated with antiretroviral medications. A national commission soon performed a systems analysis of the adverse event. Besides the active error committed during the manual transcription for the HIV lab test result, the commission also identified technological factors, such as the lack of integration between the lab machine, the laboratory information system (LIS), and the donor record, as well as organizational factors, such as the distribution to two different labs of the suitability evaluation for organs and tissues. Recommendations included: automatic transmission of lab test results from the lab machine to the LIS and to the donor record, centralization of lab tests for suitability evaluation of organs and tissues, a training program to develop a proactive quality and safety culture in the regional network of donation and transplantations. [Copyright &y& Elsevier]